U.S. Medical Eligibility Criteria for Contraceptive Use, 2024">Appendix A: Summary of Classifications for U.S. Medical Eligibility Criteria for Contraceptive Use, 2024
Health care providers can use the summary table as a quick reference guide to the classifications for hormonal contraceptive methods and intrauterine contraception to compare classifications across these methods (
###
U.S. MEC 1 = A condition for which there is no restriction for the use of the contraceptive method
U.S. MEC 2 = A condition for which the advantages of using the method generally outweigh the theoretical or proven risks
U.S. MEC 3 = A condition for which the theoretical or proven risks usually outweigh the advantages of using the method
U.S. MEC 4 = A condition that represents an unacceptable health risk if the contraceptive method is used
Abbreviation: U.S. MEC = U.S. Medical Eligibility Criteria for Contraceptive Use.
| Condition | Cu-IUD | LNG-IUD | Implant | DMPA | POP | CHC | ||||
|---|---|---|---|---|---|---|---|---|---|---|
| Personal Characteristics and Reproductive History | ||||||||||
| Pregnancy | 4* | 4* | NA* | NA* | NA* | NA* | ||||
| Age | Menarche to 45 years: 1 | >45 years: 2 | >45 years: 1 | |||||||
| Parity | ||||||||||
| a. Nulliparous | 2 | 2 | 1 | 1 | 1 | 1 | ||||
| b. Parous | 1 | 1 | 1 | 1 | 1 | 1 | ||||
| Breastfeeding | ||||||||||
| a. 42 days postpartum | — | — | 1* | 1* | 1* | 2* | ||||
| Postpartum (nonbreastfeeding) | ||||||||||
| a. 42 days postpartum | — | — | 1 | 1 | 1 | 1 | ||||
| Postpartum (including cesarean delivery, breastfeeding, or nonbreastfeeding) | ||||||||||
| a. 20 years’ duration are associated with increased risk for adverse health events as a result of pregnancy. | ||||||||||
| a. History of gestational disease | 1 | 1 | 1 | 1 | 1 | 1 | ||||
| b. Nonvascular disease | ||||||||||
| i. Non-insulin dependent | 1 | 2 | 2 | 2 | 2 | 2 | ||||
| ii. Insulin dependent | 1 | 2 | 2 | 2 | 2 | 2 | ||||
| c. Nephropathy, retinopathy, or neuropathy | 1 | 2 | 2 | 3 | 2 | 3/4* | ||||
| d. Other vascular disease or diabetes of >20 years’ duration | 1 | 2 | 2 | 3 | 2 | 3/4* | ||||
| Thyroid disorders | ||||||||||
| a. Simple goiter | 1 | 1 | 1 | 1 | 1 | 1 | ||||
| b. Hyperthyroid | 1 | 1 | 1 | 1 | 1 | 1 | ||||
| c. Hypothyroid | 1 | 1 | 1 | 1 | 1 | 1 | ||||
| Gastrointestinal Conditions | ||||||||||
| Inflammatory bowel disease (ulcerative colitis or Crohn’s disease) | 1 | 1 | 1 | 2 | 2 | 2/3* | ||||
| Gallbladder disease | ||||||||||
| a. Asymptomatic | 1 | 2 | 2 | 2 | 2 | 2 | ||||
| b. Symptomatic | ||||||||||
| i. Current | 1 | 2 | 2 | 2 | 2 | 3 | ||||
| ii. Treated by cholecystectomy | 1 | 2 | 2 | 2 | 2 | 2 | ||||
| iii. Medically treated | 1 | 2 | 2 | 2 | 2 | 3 | ||||
| History of cholestasis | ||||||||||
| a. Pregnancy related | 1 | 1 | 1 | 1 | 1 | 2 | ||||
| b. Past COC related | 1 | 2 | 2 | 2 | 2 | 3 | ||||
| Viral hepatitis | Initiation | Continuation | ||||||||
| a. Acute or flare | 1 | 1 | 1 | 1 | 1 | 3/4* | 2 | |||
| b. Chronic | 1 | 1 | 1 | 1 | 1 | 1 | 1 | |||
| Cirrhosis Decompensated cirrhosis is associated with increased risk for adverse health events as a result of pregnancy. | ||||||||||
| a. Compensated (normal liver function) | 1 | 1 | 1 | 1 | 1 | 1 | ||||
| b. Decompensated (impaired liver function) | 1 | 2 | 2 | 3 | 2 | 4 | ||||
| Liver tumors Hepatocellular adenoma and malignant liver tumors are associated with increased risk for adverse health events as a result of pregnancy. | ||||||||||
| a. Benign | ||||||||||
| i. Focal nodular hyperplasia | 1 | 2 | 2 | 2 | 2 | 2 | ||||
| ii. Hepatocellular adenoma | 1 | 2 | 2 | 3 | 2 | 4 | ||||
| b. Malignant (hepatocellular carcinoma) | 1 | 3 | 3 | 3 | 3 | 4 | ||||
| Respiratory Conditions | ||||||||||
| Cystic fibrosis This condition is associated with increased risk for adverse health events as a result of pregnancy. | 1* | 1* | 1* | 2* | 1* | 1* | ||||
| Hematologic Conditions | ||||||||||
| Thalassemia | 2 | 1 | 1 | 1 | 1 | 1 | ||||
| Sickle cell disease This condition is associated with increased risk for adverse health events as a result of pregnancy. | 2 | 1 | 1 | 2/3* | 1 | 4 | ||||
| Iron-deficiency anemia | 2 | 1 | 1 | 1 | 1 | 1 | ||||
| Solid Organ Transplantation | ||||||||||
| Solid organ transplantation This condition is associated with increased risk for adverse health events as a result of pregnancy. | Initiation | Continuation | Initiation | Continuation | — | |||||
| a. No graft failure | 1 | 1 | 1 | 1 | 2 | 2/3* | 2 | 2* | ||
| b. Graft failure | 2 | 1 | 2 | 1 | 2 | 2/3* | 2 | 4 | ||
| Drug Interactions | ||||||||||
| Antiretrovirals used for prevention (PrEP) or treatment of HIV infection | ||||||||||
| See the following guidelines for the most up-to-date recommendations on drug-drug interactions between hormonal contraception and antiretrovirals: 1) Recommendations for the Use of Antiretroviral Drugs During Pregnancy and Interventions to Reduce Perinatal HIV Transmission in the United ( https://clinicalinfo.hiv.gov/en/guidelines/perinatal/prepregnancy-counseling-childbearing-age-overview?view=full#table-3 ) ( 5 ) and 2) Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV ( https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/drug-interactions-overview?view=full ) ( 6 ). | ||||||||||
| a. Nucleoside reverse transcriptase inhibitors (NRTIs) | Initiation | Continuation | Initiation | Continuation | — | |||||
| i. Abacavir (ABC) | 1/2* | 1* | 1/2* | 1* | 1 | 1 | 1 | 1 | ||
| ii. Tenofovir (TDF) | 1/2* | 1* | 1/2* | 1* | 1 | 1 | 1 | 1 | ||
| iii. Zidovudine (AZT) | 1/2* | 1* | 1/2* | 1* | 1 | 1 | 1 | 1 | ||
| iv. Lamivudine (3TC) | 1/2* | 1* | 1/2* | 1* | 1 | 1 | 1 | 1 | ||
| v. Didanosine (DDI) | 1/2* | 1* | 1/2* | 1* | 1 | 1 | 1 | 1 | ||
| vi. Emtricitabine (FTC) | 1/2* | 1* | 1/2* | 1* | 1 | 1 | 1 | 1 | ||
| vii. Stavudine (D4T) | 1/2* | 1* | 1/2* | 1* | 1 | 1 | 1 | 1 | ||
| b. Nonnucleoside reverse transcriptase inhibitors (NNRTIs) | ||||||||||
| i. Efavirenz (EFV) | 1/2* | 1* | 1/2* | 1* | 2* | 1* | 2* | 2* | ||
| ii. Etravirine (ETR) | 1/2* | 1* | 1/2* | 1* | 1 | 1 | 1 | 1 | ||
| iii. Nevirapine (NVP) | 1/2* | 1* | 1/2* | 1* | 1 | 1 | 1 | 1 | ||
| iv. Rilpivirine (RPV) | 1/2* | 1* | 1/2* | 1* | 1 | 1 | 1 | 1 | ||
| c. Ritonavir-boosted protease inhibitors | ||||||||||
| i. Ritonavir-boosted atazanavir (ATV/r) | 1/2* | 1* | 1/2* | 1* | 2* | 1* | 2* | 2* | ||
| ii. Ritonavir-boosted darunavir (DRV/r) | 1/2* | 1* | 1/2* | 1* | 2* | 1* | 2* | 2* | ||
| iii. Ritonavir-boosted fosamprenavir (FPV/r) | 1/2* | 1* | 1/2* | 1* | 2* | 1* | 2* | 2* | ||
| iv. Ritonavir-boosted lopinavir (LPV/r) | 1/2* | 1* | 1/2* | 1* | 1 | 1 | 1 | 1 | ||
| v. Ritonavir-boosted saquinavir (SQV/r) | 1/2* | 1* | 1/2* | 1* | 2* | 1* | 2* | 2* | ||
| vi. Ritonavir-boosted tipranavir (TPV/r) | 1/2* | 1* | 1/2* | 1* | 2* | 1* | 2* | 2* | ||
| d. Protease inhibitors without ritonavir | ||||||||||
| i. Atazanavir (ATV) | 1/2* | 1* | 1/2* | 1* | 1 | 1 | 1 | 2* | ||
| ii. Fosamprenavir (FPV) | 1/2* | 1* | 1/2* | 1* | 2* | 2* | 2* | 3* | ||
| iii. Indinavir (IDV) | 1/2* | 1* | 1/2* | 1* | 1 | 1 | 1 | 1 | ||
| iv. Nelfinavir (NFV) | 1/2* | 1* | 1/2* | 1* | 2* | 1* | 2* | 2* | ||
| e. CCR5 co-receptor antagonists | ||||||||||
| i. Maraviroc (MVC) | 1/2* | 1* | 1/2* | 1* | 1 | 1 | 1 | 1 | ||
| f. HIV integrase strand transfer inhibitors | ||||||||||
| i. Raltegravir (RAL) | 1/2* | 1* | 1/2* | 1* | 1 | 1 | 1 | 1 | ||
| ii. Dolutegravir (DTG) | 1/2* | 1* | 1/2* | 1* | 1 | 1 | 1 | 1 | ||
| iii. Elvitegravir (EVG) | 1/2* | 1* | 1/2* | 1* | 1 | 1 | 1 | 1 | ||
| g. Fusion inhibitors | ||||||||||
| i. Enfuvirtide | 1/2* | 1* | 1/2* | 1* | 1 | 1 | 1 | 1 | ||
| Anticonvulsant therapy | ||||||||||
| a. Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, and oxcarbazepine) | 1 | 1 | 2* | 1* | 3* | 3* | ||||
| b. Lamotrigine | 1 | 1 | 1 | 1 | 1 | 3* | ||||
| Antimicrobial therapy | ||||||||||
| a. Broad-spectrum antibiotics | 1 | 1 | 1 | 1 | 1 | 1 | ||||
| b. Antifungals | 1 | 1 | 1 | 1 | 1 | 1 | ||||
| c. Antiparasitics | 1 | 1 | 1 | 1 | 1 | 1 | ||||
| d. Rifampin or rifabutin therapy | 1 | 1 | 2* | 1* | 3* | 3* | ||||
| Psychotropic medications | ||||||||||
| a. Selective serotonin reuptake inhibitors (SSRIs) | 1 | 1 | 1 | 1 | 1 | 1 | ||||
| St. John’s wort | 1 | 1 | 2 | 1 | 2 | 2 |
- Consult the respective appendix for each contraceptive method in U.S. Medical Eligibility Criteria for Contraceptive Use, 2024 (1) for clarifications to the numeric categories.
References
- Nguyen AT, Curtis KM, Tepper NK, et al. U.S. medical eligibility criteria for contraceptive use, 2024. MMWR Recomm Rep 2024;73(No. RR-4):1–126.
- Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. https://doi.org/10.15585/mmwr.rr7004a1
- CDC. US Public Health Service preexposure prophylaxis for the prevention of HIV infection in the United States—2021 update: a clinical practice guideline. Atlanta, GA: US Department of Health and Human Services, CDC; 2021. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf
- The Criteria Committee of the New York Heart Association. Nomenclature and criteria for diagnosis of diseases of the heart and great vessels. 9th ed. Boston, MA: Little, Brown and Co; 1994.
- Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States. Washington, DC: US Department of Health and Human Services; 2023. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/recommendations-arv-drugs-pregnancy-overview
- Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in adults and adolescents with HIV. Washington, DC: US Department of Health and Human Services; 2023. https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-arv/guidelines-adult-adolescent-arv.pdf
Appendix B: When To Start Using Specific Contraceptive Methods
This appendix summarizes recommendations for when to start using specific contraceptive methods (
| Contraceptive method | When to start (if the provider is reasonably certain that the patient is not pregnant)* | Additional contraception (i.e., back-up) needed | Examination or test needed before initiation † |
|---|---|---|---|
| Cu-IUD | Anytime | Not needed | Bimanual examination and cervical inspection § |
| LNG-IUD | Anytime | If >7 days after menses started, abstain from sexual intercourse or use barrier methods (e.g., condoms) for 7 days | Bimanual examination and cervical inspection § |
| Implant | Anytime ¶ | If >5 days after menses started, abstain from sexual intercourse or use barrier methods (e.g., condoms) for 7 days | None |
| DMPA | Anytime ¶ | If >7 days after menses started, abstain from sexual intercourse or use barrier methods (e.g., condoms) for 7 days | None |
| CHC | Anytime ¶ | If >5 days after menses started, abstain from sexual intercourse or use barrier methods (e.g., condoms) for 7 days | Blood pressure measurement |
| Norethindrone or norgestrel POP | Anytime ¶ | If >5 days after menses started, abstain from sexual intercourse or use barrier methods (e.g., condoms) for 2 days | None |
| Drospirenone POP | Anytime ¶ | If >1 day after menses started, abstain from sexual intercourse or use barrier methods (e.g., condoms) for 7 days | None |
- As appropriate, see recommendations for Emergency Contraception.
† Weight (BMI) measurement is not needed to determine medical eligibility for any methods of contraception because all methods can be used (U.S. MEC 1) or generally can be used (U.S. MEC 2) among patients with obesity (BMI ≥30 kg/m2). However, measuring weight and calculating BMI (weight [kg]/height [m]2) at baseline might be helpful for discussing concerns about any changes in weight and whether changes might be related to use of the contraceptive method.
§ Most patients do not require additional STI screening at the time of IUD placement. If a patient with risk factors for STIs has not been screened for gonorrhea and chlamydia according to CDC’s Sexually Transmitted Infections Treatment Guidelines (https://www.cdc.gov/std/treatment-guidelines/default.htm), screening may be performed at the time of IUD placement, and placement should not be delayed. Patients with current purulent cervicitis or chlamydial infection or gonococcal infection should not undergo IUD placement (U.S. MEC 4).
¶ In situations in which the health care provider is uncertain whether the patient might be pregnant, the benefits of starting the implant, DMPA, CHC, and POP likely exceed any risk; therefore, starting the implant, DMPA, CHC, and POP should be considered at any time, with a follow-up pregnancy test in 2–4 weeks.
Appendix C: Examinations and Tests Needed Before Initiation of Contraceptive Methods
The examinations and tests noted apply to patients who are presumed to be healthy (
- Class A: Essential and mandatory in all circumstances for safe and effective use of the contraceptive method.
- Class B: Contributes substantially to safe and effective use, but implementation may be considered within the public health context, service context, or both; risk of not performing an examination or test should be balanced against the benefits of making the contraceptive method available.
- Class C: Does not contribute substantially to safe and effective use of the contraceptive method.
These classifications focus on the relation of the examinations or tests to safe initiation of a contraceptive method. They are not intended to address the appropriateness of these examinations or tests in other circumstances. For example, certain examinations or tests that are not deemed necessary for safe and effective contraceptive use might be appropriate for good preventive health care or for diagnosing or assessing suspected medical conditions. Any additional screening needed for preventive health care can be performed at the time of contraception initiation, and initiation should not be delayed for test results.
No examinations or tests are needed before initiating condoms, spermicides, or vaginal pH modulators. A bimanual examination is necessary for diaphragm fitting. A bimanual examination and cervical inspection are needed for cervical cap fitting.
| Examination or test | Contraceptive method and class | |||||||
|---|---|---|---|---|---|---|---|---|
| Cu-IUD and LNG-IUD | Implant | DMPA | CHC | POP | Condom | Spermicide and vaginal pH modulator | Diaphragm/Cap (with spermicide) | |
| Examination | ||||||||
| Blood pressure | C | C | C | A* | C | C | C | C |
| Weight (BMI) (weight [kg]/height [m] 2 ) | — † | — † | — † | — † | — † | C | C | C |
| Clinical breast examination | C | C | C | C | C | C | C | C |
| Bimanual examination and cervical inspection | A | C | C | C | C | C | C | A § |
| Laboratory test | ||||||||
| Glucose | C | C | C | C | C | C | C | C |
| Lipids | C | C | C | C | C | C | C | C |
| Liver enzymes | C | C | C | C | C | C | C | C |
| Hemoglobin | C | C | C | C | C | C | C | C |
| Thrombophilia | C | C | C | C | C | C | C | C |
| Cervical cytology (Papanicolaou test) | C | C | C | C | C | C | C | C |
| STI screening with laboratory tests | — ¶ | C | C | C | C | C | C | C |
| HIV screening with laboratory tests | C | C | C | C | C | C | C | C |
- In instances in which blood pressure cannot be measured by a provider, blood pressure measured in other settings can be reported by the patient to their provider.
† Weight (BMI) measurement is not needed to determine medical eligibility for any methods of contraception because all methods can be used (U.S. MEC 1) or generally can be used (U.S. MEC 2) among patients with obesity (BMI ≥30 kg/m2). However, measuring weight and calculating BMI at baseline might be helpful for discussing concerns about any changes in weight and whether changes might be related to use of the contraceptive method.
§ A bimanual examination (not cervical inspection) is needed for diaphragm fitting.
¶ Most patients do not require additional STI screening at the time of IUD placement. If a patient with risk factors for STIs has not been screened for gonorrhea and chlamydia according to CDC’s Sexually Transmitted Infections Treatment Guidelines (https://www.cdc.gov/std/treatment-guidelines/default.htm), screening may be performed at the time of IUD placement, and placement should not be delayed. Patients with current purulent cervicitis or chlamydial infection or gonococcal infection should not undergo IUD placement (U.S. MEC 4).
References
- Nguyen AT, Curtis KM, Tepper NK, et al. U.S. medical eligibility criteria for contraceptive use, 2024. MMWR Recomm Rep 2024;73(No. RR-4):1–126.
- World Health Organization. Selected practice recommendations for contraceptive use, 2nd ed. Geneva, Switzerland: WHO Press; 2004.
Appendix D: Routine Follow-Up After Contraceptive Initiation
This appendix addresses when routine follow-up is recommended for safe and effective continued use of contraception for healthy patients (
| Action | Contraceptive method | ||||
|---|---|---|---|---|---|
| Cu-IUD or LNG-IUD | Implant | DMPA | CHC | POP | |
| General follow-up | |||||
| Advise the patient that they may contact their provider at any time to discuss side effects or other problems or if they want to change the method. Advise patients using IUDs, implants, or DMPA when the IUD or implant needs to be removed or when a reinjection is needed. No routine follow-up visit is required. | X* | X* | X* | X* | X* |
| Other routine visits | |||||
| Assess the patient’s satisfaction with their current method and whether they have any concerns about method use. | X* | X* | X* | X* | X* |
| Assess any changes in health status, including medications, that would change the method’s appropriateness for safe and effective continued use on the basis of U.S. MEC (i.e., category 3 and 4 conditions and characteristics) (Box 2). | X* | X* | X* | X* | X* |
| Consider performing an examination to check for the presence of IUD strings. | X* | — † | — † | — † | — † |
| Consider assessing weight changes and discussing concerns about any changes in weight and whether changes might be related to use of the contraceptive method. | X* | X* | X* | X* | X* |
| Measure blood pressure. | — † | — † | — † | X* | — † |
- The action is applicable to the contraceptive method.
† The action is not applicable to the contraceptive method.
Appendix E: Management of Bleeding Irregularities While Using Contraception
This appendix summarizes recommendations for management of bleeding irregularities while using contraception (
FIGURE E1. Management of bleeding irregularities while using contraception*
Abbreviations: CHC = combined hormonal contraceptive; COC = combined oral contraceptive; Cu-IUD = copper intrauterine device; DMPA = depot medroxyprogesterone acetate; EE = ethinyl estradiol; LNG-IUD = levonorgestrel intrauterine device; NSAID = nonsteroidal anti-inflammatory drug; SERM = selective estrogen receptor modulator.
- If clinically indicated, consider an underlying health condition, such as interactions with other medications, sexually transmitted infections, pregnancy, thyroid disorders, or new pathologic uterine conditions (e.g., polyps or fibroids). If an underlying health condition is found, treat the condition or refer for care.
Appendix F: Management of Intrauterine Devices When Users Are Found To Have Pelvic Inflammatory Disease
This appendix summarizes recommendations for management of intrauterine devices when users are found to have pelvic inflammatory disease (
FIGURE F1. Management of intrauterine devices when users of copper intrauterine devices or levonorgestrel intrauterine devices are found to have pelvic inflammatory disease*
Abbreviations: IUD = intrauterine device; PID = pelvic inflammatory disease.
- Refer to CDC Sexually Transmitted Infections Treatment Guidelines (https://www.cdc.gov/std/treatment-guidelines/default.htm) for information on PID diagnostic considerations and treatment regimens.
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